Dyspnea in lung cancer.7 oct2011

Wissam Abouzgheib, MD, FCCPWissam Abouzgheib, MD, FCCP

Pulmonary / Critical Care and Interventional Pulmonary / Critical Care and Interventional PulmonaryPulmonary

Sparks Health System, Fort Smith, ARSparks Health System, Fort Smith, AR

Dyspnea in Dyspnea in Lung cancerLung cancer

DisclosuresDisclosures NoneNone

56 y.o male presented with significant dyspnea and abnormal

CXR

56 y.o male presented with significant dyspnea and abnormal CXR

56 y.o male presented with significant dyspnea and abnormal CXR

56 y.o male presented with significant dyspnea and abnormal CXR

DefinitionDefinition Subjective experience of breathing Subjective experience of breathing

discomfort that consists of discomfort that consists of qualitatively distinct sensations that qualitatively distinct sensations that vary in intensity.vary in intensity.

Derives from interaction among Derives from interaction among multiple physiologic, psychological multiple physiologic, psychological and environmental factors and environmental factors

May induce 2May induce 2ndaryndary physiological and physiological and behavioral responsesbehavioral responses

PrevalencePrevalence Common and prevalence increases Common and prevalence increases

as death approachesas death approaches 70% last 6 wks of life 70% last 6 wks of life 60% of pts at diagnosis 60% of pts at diagnosis 90% advanced disease90% advanced disease

Dyspnea in terminally ill cancer patients. Chest 89:234-236

EtiologiesEtiologies

In advanced cancer: usually In advanced cancer: usually multifactorial multifactorial

Majority of underlying causes Majority of underlying causes irreversible irreversible

Palliative treatments partially successful Palliative treatments partially successful Important to reverse what is reversible Important to reverse what is reversible Relatively small improvement in Relatively small improvement in

different parameters may give different parameters may give significant reliefsignificant relief

Burden/BenefitBurden/Benefit

Burden/Benefit of the intervention for Burden/Benefit of the intervention for the patient needs to be evaluated by the patient needs to be evaluated by themthem

If extra visits to hospital are required, If extra visits to hospital are required, will the relief provided exceed the will the relief provided exceed the exhaustion incurred?exhaustion incurred?

InvestigateInvestigate Should be investigatedShould be investigated

Certain causes easily identifiable and Certain causes easily identifiable and reversiblereversible

Minimal interventionMinimal intervention

Rapid symptom improvement Rapid symptom improvement

EtiologiesEtiologies

Co-morbidities Cancer

Treatment

Co-morbiditiesCo-morbidities Infection/pneumoniaInfection/pneumonia

Increased dead space: COPD, Increased dead space: COPD, pulmonary vascular diseasepulmonary vascular disease

Resp muscle weakness: myasthenia Resp muscle weakness: myasthenia gravis, lambert-Eatongravis, lambert-Eaton

Cancer relatedCancer related AnemiaAnemia CachexiaCachexia Lymphangitic spreadLymphangitic spread Tumor obstructing an airwayTumor obstructing an airway Malignant pleural effusionMalignant pleural effusion Trapped lung Trapped lung Pulmonary embolismPulmonary embolism Conditions affecting chest wall compliance: hepatomegaly, Conditions affecting chest wall compliance: hepatomegaly,

ascites, pleural diseasesascites, pleural diseases Pulmonary congestion: SVCO, pericardial effusionPulmonary congestion: SVCO, pericardial effusion AnxietyAnxiety

Treatment-Treatment-relatedrelated Infection/pneumoniaInfection/pneumonia

DeconditioningDeconditioning

AnemiaAnemia

Pulmonary fibrosis Pulmonary fibrosis

Clinical Management Clinical Management

Non Non Pharmacological Pharmacological interventionsinterventions

Pharmacological Pharmacological interventionsinterventions

Treatable conditions - Treatable conditions - PneumoniaPneumonia

CAP and MDR pathogensCAP and MDR pathogens

Broad spectrum then deescalate Broad spectrum then deescalate

Initial management: Therapeutic Initial management: Therapeutic thoracentesisthoracentesis

MPEs inevitably re-accumulateMPEs inevitably re-accumulate Pleurodesis : Medical pleuroscopy vs Pleurodesis : Medical pleuroscopy vs

chest tube slurry talc pleurodesischest tube slurry talc pleurodesis Advanced disease = poor Advanced disease = poor

performance status performance status

Treatable conditions Treatable conditions Malignant pleural effusionMalignant pleural effusion

Treatable conditions Treatable conditions Malignant pleural effusionMalignant pleural effusion

Medical Pleuroscopy Medical Pleuroscopy availableavailable

Diagnostic and Diagnostic and therapeutic therapeutic

Lung / breast > slurry Lung / breast > slurry talctalc

Perceived more Perceived more comfortable and less comfortable and less painfulpainful

Treatable conditions Treatable conditions Malignant pleural effusionMalignant pleural effusion

Chest 2005;127;909-915

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Treatable conditions Treatable conditions Malignant pleural effusionMalignant pleural effusion

Pleurx Catheter : minimally Pleurx Catheter : minimally invasive, outpt procedure, invasive, outpt procedure, easily managed @ home or easily managed @ home or hospice hospice

Effective, relief of dyspnea Effective, relief of dyspnea > 90 % pts> 90 % pts

Pleurodesis can be Pleurodesis can be achieved in 42-58% within achieved in 42-58% within 4 wks 4 wks

Easily removableEasily removable

Curr Opin Pulm Med 2002

20-30% lung cancer during course of 20-30% lung cancer during course of diseasedisease

Bronchial > tracheal but more seriousBronchial > tracheal but more serious Endobronchial tumor, extrinsic

compression, or combination Endobronchial interventions quicker

than radiation or PDT

Treatable conditions Treatable conditions Central Airway ObstructionCentral Airway Obstruction

Electrocautery, APC, Nd-Yag,cryotherapy Debulking : certainly improves dyspnea but

? survival compared with historical controls Debulking alone unlikely affects survival Rapid / effective restoration of airway

patency and elimination of associated high morbidity and mortality of CAO were more likely responsible for this survival advantage.

Treatable conditions Treatable conditions Central Airway ObstructionCentral Airway Obstruction

20 pts20 pts ProspectiveProspective Absence of Absence of

concurrent therapyconcurrent therapy Nd-Yag laser, Nd-Yag laser,

Cryotherapy, stents, Cryotherapy, stents, laser and mechanical laser and mechanical debulking debulking

Treatable conditions Treatable conditions Central Airway ObstructionCentral Airway Obstruction

Respiration 2008;76:421–428

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Superior Vena Cava Superior Vena Cava syndrome syndrome

Facial and upper Facial and upper thoracic edemathoracic edema

Often associated with Often associated with dyspnea and coughdyspnea and cough

Traditional trts: EBRT Traditional trts: EBRT ± ± chemo, 60-75 % reponse chemo, 60-75 % reponse rate 2 weeks laterrate 2 weeks later

Endovascular stenting Endovascular stenting 95-100% relief of 95-100% relief of obstruction within 72 hrs obstruction within 72 hrs

Ann Thorac Surg. 2003

Non Pharmacological Non Pharmacological interventionsinterventions

Eclectic range of interventionsEclectic range of interventions Not systematically validated Not systematically validated self initiated self initiated Promotes self efficacyPromotes self efficacy

The fanThe fan Facial cooling 2nd and 3rd branchesFacial cooling 2nd and 3rd branches Reduces sensation of dyspneaReduces sensation of dyspnea CheapCheap SmallSmall Self initiatedSelf initiated

Am Rev Respir Dis. 1987 Jul;136(1):58-61.

Anxiety-reduction trainingAnxiety-reduction training

Learning diaphragmatic Learning diaphragmatic breathingbreathing

Reducing hyperventilationReducing hyperventilation Relaxation techniqueRelaxation technique Self hypnosisSelf hypnosis Visualization and guided imageryVisualization and guided imagery DistractionDistraction ““Dyspnea not harmful” may Dyspnea not harmful” may

reduce anxietyreduce anxiety

Methods need to fit with Methods need to fit with patient’s and relative’s patient’s and relative’s philosophy of carephilosophy of care

Part of “dyspnea Part of “dyspnea management program”management program”

Physical Physical rehabilitationrehabilitation Pulmonary rehab reduces dyspnea Pulmonary rehab reduces dyspnea

and improves QOL COPD and improves QOL COPD Even severely disabledEven severely disabled No comparable research in cancerNo comparable research in cancer Exercise training associated with Exercise training associated with

reduction in lactate levels and reduction in lactate levels and minute ventilationminute ventilation

Non invasive ventilationNon invasive ventilation

Reserved for patients with Reserved for patients with “reversible cause and to prolong life “reversible cause and to prolong life in order to achieve a specific goalin order to achieve a specific goal

COPD data: NIV might have a role in COPD data: NIV might have a role in symptom control symptom control

Crit Rev Oncol Hematol. 2004 Aug;51(2):91-103.

Pharmacological management - Pharmacological management - OpioidsOpioids

Most case reports or seriesMost case reports or series

Jenings et al: metanalysis double Jenings et al: metanalysis double blinded, randomized, placebo blinded, randomized, placebo controlled trials controlled trials

Nebulized opioids = placeboNebulized opioids = placebo

Thorax. 2002 Nov;57(11):939-44. Review.

Pharmacological management - Pharmacological management - OpioidsOpioids

Thorax. 2002 Nov;57(11):939-44. Review.

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Pharmacological management - Pharmacological management - OpioidsOpioids

Randomized, double blind, placebo controlled Randomized, double blind, placebo controlled crossover trial of sustained release morphine for crossover trial of sustained release morphine for the management of refractory dyspnea.the management of refractory dyspnea.

6/38 pts had cancer6/38 pts had cancer 20mg modified-release morphine 4 days followed 20mg modified-release morphine 4 days followed

by 4 days placebo or vice versa by 4 days placebo or vice versa 5-10% improvement in dyspnea over baseline all 5-10% improvement in dyspnea over baseline all

ptspts Better sleep during treatment periodBetter sleep during treatment period No respiratory depressionNo respiratory depression

BMJ. 2003 Sep 6;327(7414):523-8.

Phenothiazines and Phenothiazines and benzodiazepinesbenzodiazepines

No randomized controlled trialsNo randomized controlled trials Phenothiazines preferred- less resp depressionPhenothiazines preferred- less resp depression beneficial effects of morphine in controlling beneficial effects of morphine in controlling

baseline levels of dyspnea could be improved baseline levels of dyspnea could be improved with the addition of midazolam to the with the addition of midazolam to the treatment.treatment.

morphine (2.5 mg Q4hrs for opioid-naïve or a morphine (2.5 mg Q4hrs for opioid-naïve or a 25% increment over daily dose for pts receiving 25% increment over daily dose for pts receiving baseline opioids) plus midazolam (5 mg Q4hrs) baseline opioids) plus midazolam (5 mg Q4hrs) with morphine rescue doses (2.5 mg)with morphine rescue doses (2.5 mg)

J Pain Symptom Manage. 2006 Jan;31(1):38-47.

OxygenOxygen Mechanism uncertainMechanism uncertain Correction of hypoxemia may not Correction of hypoxemia may not

alleviate dyspneaalleviate dyspnea May be activation trigeminal nerveMay be activation trigeminal nerve Randomized trials suggest that both Randomized trials suggest that both

O2 and air can reduce dyspnea in O2 and air can reduce dyspnea in cancer patientscancer patients

HelioxHeliox Less dense than airLess dense than air When mixed with O2, reduces When mixed with O2, reduces

turbulent flow in narrowed airwaysturbulent flow in narrowed airways Reduces work of breathing and Reduces work of breathing and

improves alveolar ventilationimproves alveolar ventilation One randomized controlled trial, Heliox One randomized controlled trial, Heliox

reduced DOE and increased exercise reduced DOE and increased exercise capacity and SaO2 at rest and exertioncapacity and SaO2 at rest and exertion

Br J Cancer. 2004 Jan 26;90(2):366-71.

Inhaled Inhaled furosemidefurosemide Randomized, double-blined, placebo Randomized, double-blined, placebo

controlled in cancer patientscontrolled in cancer patients

No beneficial effectNo beneficial effect

Thorax. 2008 Oct;63(10):872-5. Epub 2008 Apr 11.

Thank youThank you